PRIMARY CARE ANTIMICROBIAL GUIDE

Transcription

1 PRIMARY CARE ANTIMICROBIAL GUIDE GENERATED AT THU DEC 27 15:17:38 UTC WHAT'S NEW IN THIS VERSION? What's new in this version? Welcome to the MicroGuide app for the four East Kent CCGs antibiotic prescribing guideline for primary care. The four East Kent CCGs include Ashford, Canterbury and Coastal, South Kent Coast and Thanet CCGs. This guideline was approved for use in East Kent from December This application will be updated as and when the East Kent CCGs guideline is updated. The full PHE (Public Health England) document can be viewed here. Updates December Update to version 1.3:

2 Added Lyme's disease Replaced guidance on UTI, acute sore throat, acute otitis media and sinusitis with NICE guidelines. Infectious diarrhoea - addition of tinidazole for giardia Traveller's diarrhoea - azithromycin now recommended instead of ciprofloxacin H.Pylori eradiction - new third line option added Vaginal candidiasis - treatment for recurrent episodes added PID - moxifloxacin added as a potential treatment option in combination with metronidazole Cellulitis - clindamycin removed Bites - ceftriaxone added as an option for pregnant penicillin allergy Fungal nail infections - amorolfine removed May Update to version Sepsis screening and Action tool -Antimicrobial resistance education and training - New e-learning modules January Update to version Supporting information - penicillin allergy- Traffic light colour coding inserted and drugs colour coded. November Update to version Bites (animal/human) Clarification and doses for treatment in children. November Update to version As per PHE September 2017 update May update to recurrent UTI section. February Updates to Urinary Tract Infections: UTI General Information, Uncomplicated UTI January First Release of Public version. December Initial launch of the East Kent CCGs MicroGuide app.

3 2 SEPSIS - RECOGNITION AND MANAGEMENT 2.1 SEPSIS SCREENING AND ACTION TOOL Sepsis Screening and Action Tool Sepsis is a time critical condition. Screening, early intervention and immediate treatment saves lives. This tool should be applied to all adult patients who are not pregnant who have a suspected infection or their clinical observations are outside of normal limits.

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5 2.2 GENERAL PRACTICE MANAGEMENT OF SEPSIS General Practice and Management of Sepsis This section contains a clinical toolkit that has been developed in partnership with the Royal College of General Practitioners. It is designed to provide operational solutions to the complexities challenging the reliable identification and management of sepsis in the primary care setting, and complements clinical toolkits designed for other clinical areas. The toolkit aims to make GPs and other primary care clinicians familiar with the significant morbidity and mortality associated with severe sepsis and to structure their knowledge and skills so that they can recognise the condition earlier. It advises on specific safety netting in patients presenting with signs and symptoms of infection and addresses the need to work collaboratively with health professionals in other clinical areas to ensure that appropriate further assessment is undertaken and time-critical care is delivered rapidly when necessary. This toolkit is compatible with international guidelines on sepsis management, with the Department of Healthâ s document â Start Smartthen Focusâ, and with guidance on infection management in primary care issued by the Health Protection Agency. Click here to view the toolkit in detail. 2.3 REFERENCES AND FURTHER INFORMATION Spotting the Sick Child Spotting the Sick Child is an interactive tool commissioned by the Department of Health and Health Education England to support health professionals in the assessment of the acutely sick child. You can register for guidance and training to improve your understanding, as children need a different approach from adults and many health professionals are anxious about assessing children. 2.4 ANTIMICROBIAL RESISTANCE EDUCATION AND TRAINING: NEW E-LEARNING MODULES

6 New e-learning modules A basic introductory free e-learning module on reducing antimicrobial resistance is available to all health and social care staff â both clinical and non-clinical - in a variety of settings to understand the threats posed by antimicrobial resistance, and ways they can help tackle this. Access resources available from HEE on antimicrobial resistance and sepsis fact sheet here. 3 PRINCIPLES OF TREATMENT Principles of Treatment 1. This guidance is based on the best available evidence, but use professional judgement and involve patients in management decisions. 2. The guidance should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website. 3. Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate. 4. If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection 5. Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice. 6. In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned. 7. Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from Limit prescribing over the telephone to exceptional cases. 9. Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of CLOSTRIDIUM DIFFICILE, MRSA and resistant UTIs. 10. Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited. 11. Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course.

7 12. Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuromuscular and skeletal side effects. 13. Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity. 14. The PHE sections of the table summary support the 2017 to 2019 NHS England Antibiotic Quality Premium ambition to reduce inappropriate antibiotic prescribing in the management of infections in primary care. 4 BODY SYSTEMS 4.1 UPPER RESPIRATORY TRACT INFECTIONS PRESCRIBING ADVICE Upper respiratory tract infections: prescribing advice Most respiratory tract infections are self-limiting, therefore antibiotics are rarely necessary. Consider a delayed antibiotic prescription strategy. Giving out antibiotics automatically for upper respiratory tract infections increases the number of future consultations for the same symptoms. The NICE pathway for respiratory tract infections states that all patients should be offered: 1. Advice about the natural history of the illness and total illness length 2. Advice regarding management of symptoms, particularly analgesics and antipyretics (a patient information leaflet is available through the RCGP TARGET toolkit) AVERAGE ILLNESS LENGTH Natural history and average illness length for common respiratory tract infections

8 4.1.3 AVERAGE TOTAL ILLNESS LENGTHS Acute otitis media - 4 days Acute sore throat/ acute pharyngitis/ acute tonsillitis - 1 week Common cold weeks Acute rhinosinusitis weeks Acute cough/ acute bronchitis - 3 weeks

9 4.1.4 NATURAL HISTORY

10 NICE PATHWAY NICE pathway for self-limiting respiratory tract infections - antibiotic prescribing overview The NICE pathway covers prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care and brings together all NICE guidance, quality standards and materials. To view the pathway click here. (Please note the pathway is best viewed on a tablet or desktop/laptop) INFLUENZA Influenza Annual vaccination is essential for all those at risk of influenza. 1D Antivirals are not recommended for healthy adults. 1D,2A+ Treat at risk patients with 5 days Oseltamivir 75mg BD, 1D when influenza is circulating in the community, and ideally within 48 hours of onset (36 hours for zanamivir treatment in children), 1D,3D or in a care home where influenza is likely. 1D,2A+ At risk: pregnant (and up to 2 weeks post-partum); children under 6 months; adults 65 years or older; chronic respiratory disease (including COPD and asthma); significant cardiovascular disease (not hypertension); severe immunosuppression; chronic neurological, renal or liver disease; diabetes mellitus; morbid obesity (BMI>40). 4D See the PHE Influenza guidance for the treatment of patients under 13 years. 4D In severe immunosuppression, or Oseltamivir resistance, use zanamivir 10mg BD 5A+,6A+ (2 inhalations by diskhaler for up to 10 days) and seek advice. 4D ACCESS SUPPORTING EVIDENCE AND RATIONALES ON THE PHE WEBSITE.

11 References and further information NICE guidance - influenza prophylaxis Public Health England - influenza treatment ACUTE OTITIS EXTERNA Acute otitis externa (AOE) First use analgesia Cure rates similar at 7 days for topical acetic acid or antibiotic +/- steroid. If cellulitis/disease extending outside ear canal, First Line Analgesia for pain relief and apply localised heat (such as a warm flannel) Second Line Topical acetic acid or topical antibiotic +/- steroid: similar cure at 7 days. Acetic acid ear spray 2% (Ear-calm )* 1 spray TDS for 7 days Ear-calm spray is available to purchase from pharmacies for less than a prescription charge

12 OR Neomycin sulphate with corticosteroid drops 3 drops TDS for a minimum of 7 days to 14 days maximum OR Otomize ear spray (neomycin sulfate with dexamethasone) 1 spray TDS for a minimum of 7 days to 14 days maximum. If cellulitis or disease extends outse of ear canal, or systemic signs of infection, start oral antibiotics and refer to exclude malignant otitis externa Flucloxacillin 250mg QDS for 7 days. For severe: 500mg QDS for 7 days Children's dosages: Children 1 month to 1 year of age â 62.5 mg to 125 mg, four times a day for 7 days. Children 2â 9 years of age â 125 mg to 250 mg, four times a day for 7 days REFERENCES AND FURTHER INFORMATION NICE Clinical Knowledge Summaries: Otitis externa ACUTE OTITIS MEDIA Acute otitis media Prescribing notes and general advice Optimise analgesia and target antibiotics

13 AOM resolves in 60% in 24hrs without antibiotics, which only reduce pain at 2 days (NNT15) and does not prevent deafness. Regular paracetamol or ibuprofen for pain (right dose for age or weight at the right time and maximum doses for severe pain). Otorrhoea or under 2 years with infection in both ears: no, back-up or immediate antibiotic. Otherwise: no or back-up antibiotic. Systemically very unwell or high risk of complications: immediate antibiotic. FOR DETAILED INFORMATION CLICK ON THE VISUAL SUMMARY. First choice Amoxicillin Neonate (7-28 days): 30mg/kg TDS (maximum per dose 125mg) for 5-7 days Child 1 month-1 year: 125mg TDS for 5-7 days Child 1-5 years: 250mg TDS for 5-7 days Child 5-17 years: 500mg TDS for 5-7 days Adult: 500mg TDS for 5-7 days Alternative ONLY if penicillin allergic Erythromycin (preferred if pregnant) Child < 2years 125mg QDS for 5-7 days Child 2-8 years: 250mg QDS for 5-7 days Child 8-18 years: mg QDS for 5-7 days

14 Adult: mg QDS for 5-7 days NB: prescribe enteric coated/ gastro resistant tablets when prescribing tablet formulation OR Clarithromycin Child 1 monthâ 11 years (body-weight up to 8 kg) 7.5 mg/kg twice daily for 5-7 days. Child 1 monthâ 11 years (body-weight 8â 11 kg) 62.5 mg twice daily for 5-7 days. Child 1 monthâ 11 years (body-weight 12â 19 kg) 125 mg twice daily for 5-7 days. Child 1 monthâ 11 years (body-weight 20â 29 kg) mg twice daily for 5-7 days.

15 Child 1 monthâ 11 years (body-weight 30â 40 kg) 250 mg twice daily for 5-7 days. Child 12â 17 years 250 mg twice daily for 5-7 days, increased to 500 mg twice daily, if required in severe infections. Second choice Co-amoxiclav tablets for 5-7 days REFERENCES AND FURTHER INFORMATION Otitis media (acute): antimicrobial prescribing visual summary NICE Clinical Knowledge Summaries: Otitis media (acute) NICE - fever in under 5s assessment and initial management ACUTE SINUSITIS Acute Sinusitis Prescribing notes and general advice

16 For symptoms <10 days do not offer antibiotics as most resolve in 14 days without. Antibiotics only offer marginal benefit after 7 days (NNT 15) For symptoms with no improvement for > 10 days no antibiotic or back-up antibiotic depending on likelihood of bacterial cause. Consider high dose nasal steroid if > 12 years. Systemically very unwell, or high risk of complications: immediate antibiotic. Suspected complications: eg sepsis, intraorbital or intracranial, refer to secondary care Self-care: Advise paracetamol/ibuprofen for pain/fever.little evidence that nasal saline or nasal decongestants help, but people may want to try them. For detailed information please see visual summary First choice Phenoxymethylpenicillin Adults: 500mg QDS for 5 days Children's dosages: For Child 1â 11 months 62.5â mg 4 times a day; increased if necessary up to 12.5â mg/kg 4 times a day. For Child 1â 5 years 125â mg 4 times a day; increased if necessary up to 12.5â mg/kg 4 times a day. For Child 6â 11 years

17 250â mg 4 times a day; increased if necessary up to 12.5â mg/kg 4 times a day. For Child 12â 17 years 500â mg 4 times a day; increased if necessary up to 1â g 4 times a day. Penicillin allergy: Doxycycline capsules for adults and children > 12 years: 200mg stat then 100mg OD for 5 days OR Clarithromycin For adults: 500mg BD for 5 days Children's dosages for 5 days For Neonate 7.5â mg/kg twice daily. For Child 1 monthâ 11 years (body-weight up to 8 kg) 7.5â mg/kg twice daily. For Child 1 monthâ 11 years (body-weight 8â 11 kg) 62.5â mg twice daily. For Child 1 monthâ 11 years (body-weight 12â 19 kg)

18 125â mg twice daily. For Child 1 monthâ 11 years (body-weight 20â 29 kg) 187.5â mg twice daily. For Child 1 monthâ 11 years (body-weight 30â 40 kg) 250â mg twice daily. For Child 12â 17 years 250â mg twice daily usually for 7â 14 days, increased to 500â mg twice daily, if required in severe infections. OR Erythromycin (Preferred if pregnant), adults: 250mg to 500mg QDS OR 500mg to 1000mg BD for 5 days Second choice or first choice if systemically very unwell or high risk of complications: Co-amoxiclav Adults: 500/125mg TDS for 5 days Children's dosages: Doses for 125/31mg suspension For Neonate

19 0.25â ml/kilogram 3 times a day. For Child 1â 11 months 0.25â ml/kilogram 3 times a day, dose doubled in severe infection. For Child 1â 5 years 0.25â ml/kilogram 3 times a day, alternatively 5â ml 3 times a day, dose doubled in severe infection Doses for 250/62mg suspension For Child 6â 11 years 0.15â ml/kilogram 3 times a day, alternatively 5â ml 3 times a day, dose doubled in severe infection DOSES FOR 400/57MG SUSPENSION For Child 2 monthsâ 1 year 0.15â ml/kilogram twice daily, doubled in severe infection. For Child 2â 6 years (body-weight 13â 21 kg) 2.5â ml twice daily, doubled in severe infection. For Child 7â 12 years (body-weight 22â 40 kg) 5â ml twice daily, doubled in severe infection. For Child 12â 17 years (body-weight 41 kg and above)

20 10â ml twice daily; increased if necessary to 10â ml 3 times a day, increased frequency to be used in severe infection. References and further information NICE Clinical Knowledge Summaries: Acute sinusitis Sinusitis (acute): antimicrobial prescribing visual summary ACUTE SORE THROAT Acute sore throat Prescribing notes and general advice Avoid Antibiotics as 82% of cases resolve in 7 days, and pain is only reduced by 16 hours. CKS Feverpain Use FeverPAIN Score : Fever in last 24 hours; Purulence; Attend rapidly under three days; severyly Inflamed tonsils; No cough or coryza. Score 0-1: 13-18% streptococci - no antibiotic 2-3: 34-40% streptococci - no or 3 day back-up antibiotic 4-5: 62-65% streptococci - immediate antibiotic or 48 hour back-up antibiotic

21 Systemically very unwell or high risk of complications: immediate antibiotic. Self care: Advise paracetamol, or if preferred and suitable ibuprofen for pain. Medicated lozenges may help pain in adults and may be purchased from pharmacies For detailed information please see visual summary First choice: Phenoxymethylpenicillin tablets 500mg QDS or 1g BD for 5-10 days Children's dosage Child 1â 11 months 62.5 mg 4 times a day for 10 days; increased if necessary up to 12.5 mg/kg 4 times a day Child 1â 5 years 125 mg 4 times a day for 10 days; increased if necessary up to 12.5 mg/kg 4 times a day Child 6â 11 years 250 mg 4 times a day for 10 days; increased if necessary up to 12.5 mg/kg 4 times a day Child 12â 17 years 500 mg 4 times a day for 10 days; increased if necessary up to 1 g 4 times a day If allergic to penicillin Clarithromycin tablets mg BD for 5 days Children's dosage Child 1 monthâ 11 years (body-weight up to 8 kg) 7.5 mg/kg twice daily for 5 days.

22 Child 1 monthâ 11 years (body-weight 8â 11 kg) 62.5 mg twice daily for 5 days. Child 1 monthâ 11 years (body-weight 12â 19 kg) 125 mg twice daily for 5 days. Child 1 monthâ 11 years (body-weight 20â 29 kg) mg twice daily for 5 days. Child 1 monthâ 11 years (body-weight 30â 40 kg) 250 mg twice daily for 5 days. Child 12â 17 years 250 mg twice daily for 5 days, increased to 500 mg twice daily, if required in severe infections. Penicillin allergy in pregnancy Erythromycin mg QDS for 5 days or 500mg-1g BD for 5 days References and further information NICE Clinical Knowledge Summaries: Acute sore throat Sore throat (acute): antimicrobial prescribing visual summary SCARLET FEVER Scarlet Fever Prescribing notes and general advice

23 Prompt treatment with appropriate antibiotics significantly reduces the risk of complications. Vulnerable individuals (immunocompromised, the co-morbid, or those with skin disease) are at increased risk of developing complications. Optimise analgesia and give safety netting advice. First Line Phenoxymethylpenicillin tablets Adult: 500mg QDS for 10 days 62.5mg QDS for children aged 1 month to 11 months 125mg for children aged 1 year to 5 years 11 months 250mg for children aged 6 years to 11 years 11 months mg for children aged 12 years to 17 years 11 months Penicillin allergy Clarithromycin tablets mg BD for 5 days Child 1 monthâ 11 years (body-weight up to 8 kg) 7.5 mg/kg twice daily for 5 days. Child 1 monthâ 11 years (body-weight 8â 11 kg) 62.5 mg twice daily for 5 days. Child 1 monthâ 11 years (body-weight 12â 19 kg) 125 mg twice daily for 5 days.

24 Child 1 monthâ 11 years (body-weight 20â 29 kg) mg twice daily for 5 days. Child 1 monthâ 11 years (body-weight 30â 40 kg) 250 mg twice daily for 5 days. Child 12â 17 years 250 mg twice daily for 5 days, increased to 500 mg twice daily, if required in severe infections. References and further information NICE Clinical Knowledge Summaries: Scarlet fever 4.2 LOWER RESPIRATORY TRACT INFECTIONS ACUTE COUGH/ BRONCHITIS Presecribing notes and general advice Acute cough/ bronchitis Antibiotics of little benefit if no co-morbidity. Antibiotics have little benefit in otherwise healthy adults so avoid. First line: self-care and safety netting advice Second line: 7 day delayed antibiotic, safety net, and advise that symptoms can last 3 weeks. Consider immediate antibiotics if >80 years of age and 1 of: hospitalisation in past year; taking oral steroids; insulin-dependent diabetic; congestive heart failure; serious neurological disorder/stroke, or >65 years with 2 of the above.

25 Consider CRP if antibiotic is being considered. No antibiotics if CRP<20mg/L and symptoms for >24 hours; delayed antibiotics if 20â 100mg/L; immediate antibiotics if >100mg/L. 5D Use paracetamol or ibuprofen as required, drink plenty of fluids. Symptom resolution can take up to 3 weeks. Second Line: Amoxicillin capsules 500mg TDS for 5 days OR Doxycycline capsules 200mg stat on day 1 then 100mg OD for a further 4 days (total treatment duration 5 days) Note: Low doses of penicillins are more likely to select out resistance hence we recommend 500mg of amoxicillin. Do NOT use quinolones (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms REFERENCES AND FURTHER INFORMATION NICE Clinical Knowledge Summaries: Chest infections (adult) NICE Clinical Guideline - respiratory tract infections (self limiting): prescribing antibiotics ACUTE EXACERBATION OF COPD Acute exacerbation of COPD

26 Treat with antibiotics only if purulent sputum and increased shortness of breath and/or increased sputum volume. Consider risk factors for antibiotic resistance: severe COPD (MRC > 3), co-morbidity, frequent exacerbations and antibiotics in the last 3 months. First Line Amoxicillin capsules 500mg TDS for 5 days OR Doxycycline capsules 200mg stat on day 1, then 100mg OD for a further 4 days (total duration of treatment 5 days) OR Clarithromycin tablets 500mg BD for 5 days Note: Low doses of penicillins are more likely to select for resistance. Do not use fluoroquinolones (ciprofloxacin, ofloxacin) first line as they may have long-term side effects and there is poor pneumococcal activity. Reserve all fluoroquinolones (including levofloxacin) for proven resistant organisms. Second Line (if at risk of resistance) Co-amoxiclav tablets 625mg TDS for 5 days! Increased risk of C.diff infection with co-amoxiclav REFERENCES AND FURTHER INFORMATION NICE Clinical Knowledge Summaries: Chest infections NICE Clinical Guideline - chronic obstructive pulmonary disease in over 16s: diagnosis and management

27 EKPG Inhaled Therapy for COPD PNEUMONIA (COMMUNITY ACQUIRED) Community acquired pneumonia (treatment in the community) Manage using clinical judgement and CRB-65 score (see below) to guide mortality risk, place of care and antibiotics. CRB-65 score for mortality risk assessment in primary care Each CRB-65 parameter scores 1: Confusion (AMT <8 or new disorientation in person, place or time) Raised respiratory rate (â 30 breaths per minute) Low blood pressure (systolic â 90mmHg or diastolic â 60mmHg) Age â 65 years Patients are stratified as follows: 0: low risk (<1% mortality risk) - consider home based care 1 or 2: intermediate risk (1-10% mortality risk) - consider hospital assessment 3 or 4: high risk (more than 10% mortality risk) - urgent hospital admission Always give safety net advice and likely duration of different symptoms eg cough 6 weeks. Clinically assess need for dual therapy for atypicals. Mycoplasma infection is rare in over 65s

28 If CRB-65 = 0 Amoxicillin capsules 500mg TDS OR Clarithromycin tablets 500mg BD OR Doxycycline capsules 200mg STAT on day 1 then 100mg OD Duration for CRB-65=0: Use 5 days. Review at 3 days and extend to 7-10 days if poor response If CRB-65 = 1 or 2 and AT HOME Clinically assess need for dual therapy for atypicals: Amoxicillin capsules 500mg TDS AND Clarithromycin tablets 500mg BD for 7-10 days OR Doxycycline capsules 200mg STAT on day 1 then 100mg OD for 7-10 days (Doxycycline provides cover against atypicals) REFERENCES AND FURTHER INFORMATION NICE Clinical Knowledge Summaries: Chest infections BTS Guidelines for the Management of Community Acquired Pneumonia

29 Pneumonia in adults: diagnosis and management NICE Clinical Guideline [CG191] December SUSPECTED MENINGITIS Suspected meningococcal disease TRANSFER ALL PATIENTS TO HOSPITAL IMMEDIATELY. IF time before hospital admission, and non-blanching rash give IV benzylpenicillin or cefotaxime. Do not give IV antibiotics if there is a definite history of anaphylaxis; rash is not a contraindication. First Line: BENZYLPENICILLIN IV INJECTION (GIVE IM IF VEIN CANNOT BE FOUND) Adults and children â 10 years of age: 1200mg Children 1 â 9 years of age: 600mg Children <1 year of age: 300mg Second Line: (penicillin allergy) CEFOTAXIME IV INJECTION (GIVE IM IF VEIN CANNOT BE FOUND) Adults and children â 12 years of age: 1 gram

30 Children <12 years of age: 50mg/kg Prescribing notes and general advice Prevention of secondary cases: Only prescribe following advice from the Public Health Doctor 9am - 5pm Out of hours: Contact on-call Doctor via switchboard Access the supporting evidence and rationales on the PHE WEBSITE References and further information NICE Clinical Knowledge Summaries: Meningitis Meningitis Research Foundation: General Practice Resources and Information 4.4 URINARY TRACT INFECTIONS UTI GENERAL INFORMATION UTI general information

31 Do not treat asymptomatic bacteriuria in the elderly (>65years); it is common and is not associated with increased morbidity. Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. References and further information REFER TO PHE UTI GUIDANCE FOR DIAGNOSIS INFORMATION As antimicrobial resistance and E. COLI bacteraemia in the community is increasing, use nitrofurantoin first line, ALWAYS give safety net and self-care advice, and consider risks for resistance. Give TARGET UTI leaflet Target UTI Leaflet for patients under 65 years Target UTI Leaflet for older adults Public Health England UTI - quick reference guide LOWER URINARY TRACT INFECTIONS Lower Urinary Tract Infection Prescribing notes and general advice For diagnostic advice please see: PHE Diagnosis of urinary tract infections: Quick reference tool for primary care Nov 2018 Advise paracetamol or ibuprofen for pain. Non-pregnant women: back up antibiotic (to use if no improvement in 48 hours or symptoms worsen at any time) or immediate antibiotic. Pregnant women, men, children or young people: immediate antibiotic. When considering antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data. FOR DETAILED INFORMATION PLEASE SEE THE VISUAL SUMMARY. SEE ALSO THE NICE GUIDELINE ON URINARY TRACT INFECTION IN UNDER 16S: DIAGNOSIS AND MANAGEMENT

32 Non-pregnant women first choice: Nitrofurantoin modified release capsules (if egfr â 45 ml/minute) OR 100mg m/r BD 3 days Trimethoprim tablets (if low risk of resistance) 200mg BD 3 days Non-pregnant women second choice: Nitrofurantoin modified release capsules (if egfr â 45 ml/minute OR 100mg m/r BD 3 days Pivmecillinam (a penicillin) OR 400mg initial dose, then 200mg TDS 3 days Fosfomycin 3g single dose sachet single dose Pregnant women first choice: Nitrofurantoin modified release capsules (avoid at term) â if egfr â 45 ml/minute Pregnant women second choice: Amoxicillin capsules (only if culture results available and susceptible) OR 100mg m/r BD 500mg TDS 7 days 7 days cefalexin 500mg BD 7 days Treatment of asymptomatic bacteriuria in pregnant women: choose from Nitrofurantoin modified release capsules (avoid at term), Amoxicillin capsules or Cefalexin capsules based on recent culture and susceptibility results Men first choice: Trimethoprim tablets OR Nitrofurantoin modified release capsules (if egfr â 45 ml/minute) 200mg BD 100mg m/r BD 7 days 7 days Men second choice: consider alternative diagnoses basing antibiotic choice on recent culture and susceptibility results Children and young people (3 months and over) first choice: Trimethoprim (if low risk of resistance) OR Nitrofurantoin (if egfr â 45 ml/minute) Children and young people (3 months and over) second choice: Nitrofurantoin (if egfr â 45 ml/minute and not used as first choice) OR Amoxicillin (only if culture results available and susceptible) OR Cefalexin Please refer to page 2 of visual summary for children's dosing information

33 4.4.4 REFER CHILDREN UNDER 3 MONTHS TO PAEDIATRIC SPECIALIST AND TREAT WITH INTRAVENOUS ANTIBIOTICS IN LINE WITH THE NICE GUIDELINE ON FEVER IN UNDER 5S REFERENCES AND FURTHER INFORMATION URINARY TRACT INFECTION (LOWER): ANTIMICROBIAL PRESCRIBING NICE GUIDELINE [NG109] PUBLISHED DATE: OCTOBER 2018 PHE Diagnosis of urinary tract infections: Quick reference tool for primary care Nov 2018 NICE GUIDELINE ON URINARY TRACT INFECTION IN UNDER 16S: DIAGNOSIS AND MANAGEMENT NICE Clinical Knowledge Summaries: Urinary tract infection (lower) - women NICE Clinical Knowledge Summaries: Urinary tract infection (lower) - men SIGN guidance: Management of suspected bacterial UTI in adults MHRA Drug Safety Update (Nitrofurantoin) September ACUTE PYELONEPHRITIS Acute pyelonephritis (upper urinary tract) Advise paracetamol (+/- low-dose weak opioid) for pain for people over 12. Offer an antibiotic. When prescribing antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data.

34 FOR DETAILED INFORMATION PLEASE SEE THE VISUAL SUMMARY. SEE ALSO THE NICE GUIDELINE ON URINARY TRACT INFECTION IN UNDER 16S: DIAGNOSIS AND MANAGEMENT Non-pregnant women and men first choice: Cefalexin capsules OR Co-amoxiclav tablets (only if culture results available and susceptible) OR Trimethoprim tablets (only if culture results available and susceptible) OR 500mg BD or TDS (up to 1g to 1.5g TDS or QDS for severe infections) 500/125mg TDS 200mg BD 7â 10 days 7â 10 days 14 days Ciprofloxacin tablets (consider safety issues) 500mg BD 7 days IV antibiotics (CLICK ON VISUAL SUMMARY) Pregnant women first choice: Cefalexin capsules Pregnant women second choice or IV antibiotics (CLICK ON VISUAL SUMMARY) Children and young people (3 months and over) first choice: Cefalexin OR Co-amoxiclav tablets (only if culture results available and susceptible) IV antibiotics (CLICK ON VISUAL SUMMARY) 500mg BD or TDS (up to 1g to 1.5g TDS or QDS for severe infections) 7â 10 days References and further information 5 PYELONEPHRITIS (ACUTE): ANTIMICROBIAL PRESCRIBING NICE GUIDELINE [NG111] PUBLISHED DATE: OCTOBER 2018 Pyelonephritis (acute): antimicrobial prescribing visual summary NICE CKS - Acute pyelonephritis NICE GUIDELINE ON URINARY TRACT INFECTION IN UNDER 16S: DIAGNOSIS AND MANAGEMENT

35 5.1.1 RECURRENT URINARY TRACT INFECTION Recurrent Urinary Tract Infection First advise about behavioural and personal hygiene measures, and self-care (with D-mannose or cranberry products) to reduce the risk of UTI. For postmenopausal women, if no improvement, consider vaginal oestrogen (review within 12 months). For non-pregnant women, if no improvement, consider single-dose antibiotic prophylaxis for exposure to a trigger (review within 6 months). For non-pregnant women (if no improvement or no identifiable trigger) or with specialist advice for pregnant women, men, children or young people, consider a trial of daily antibiotic prophylaxis (review within 6 months). For detailed information please see the visual summary. See also the NICE guideline on URINARY TRACT INFECTION IN UNDER 16S: DIAGNOSIS AND MANAGEMENT First choice antibiotic prophylaxis: Trimethoprim tablets (avoid in pregnancy) OR Nitrofurantoin (avoid at term) - if egfr â 45 ml/minute Second choice antibiotic prophylaxis: Amoxicillin capsules OR Cefalexin capsules 200mg single dose when exposed to a trigger or 100mg at night 100mg single dose when exposed to a trigger or 50 to 100mg at night 500mg single dose when exposed to a trigger or 250mg at night 500mg single dose when exposed to a trigger or 125mg at night For dosing in children please refer to the visual summary Notes This guidance relates to patients being treated in primary care. More complex patients under the care of urologists may require alternative prophylactic antibiotics tailored to their individual needs and sensitivity patterns. This may involve the use of rotational antibiotics.

36 Rotational antibiotics should not be initiated in primary care except on consultant microbiologist or urology advice. References and further information Urinary tract infection (recurrent): antimicrobial prescribing NICE guideline [NG112] Published date: October 2018 UTI (recurrent): antimicrobial prescribing visual summary NICE guideline on URINARY TRACT INFECTION IN UNDER 16S: DIAGNOSIS AND MANAGEMENT ACUTE PROSTATITIS Acute prostatitis Advise paracetamol (+/- low-dose weak opioid) for pain, or ibuprofen if preferred and suitable. Offer antibiotic. Review antibiotic treatment after 14 days and either stop antibiotics or continue for a further 14 days if needed (based on assessment of history, symptoms, clinical examination, urine and blood tests). FOR DETAILED INFORMATION PLEASE SEE THE VISUAL SUMMARY. First choice (guided susceptibilities when available): Ciprofloxacin tablets OR 500mg BD 14 days then review Ofloxacin tablets OR 200mg BD 14 days then review Trimethoprim tablets (if unable to take quinolone) 200mg BD 14 days, then review Second choice (after discussion with specialist): Levofloxacin OR 500mg OD 14 days, then review co-trimoxazole 960mg BD 14 days, then review IV antibiotics (CLICK ON VISUAL SUMMARY)

37 References and further information Prostatitis (acute): antimicrobial prescribing NICE guideline [NG110] Published date: October 2018 Prostatitis (acute): antimicrobial prescribing visual summary NICE Clinical Knowledge Summaries - Acute prostatitis PATIENTS WITH CATHETERS IN SITU Patients with catheters in situ WHEN TO TREAT For every day a catheter is left in, 5-10% of patients will become colonised with bacteria. Unless catheterisation is short term all patients can be assumed to have bacteria in their urine. In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell (pyrexial) or pyelonephritis likely. Do not use prophylactic antibiotics for catheter changes unless history of catheter change associated UTI or trauma. Take sample if new onset of delirium, or two or more symptoms of UTI PRESCRIBING NOTES AND GENERAL ADVICE Do not use dipstick testing to diagnose UTI in patients with catheters. A catheter specimen of urine sample is necessary in suspected catheter related UTI but CSU samples should not be sent in the absence of clinical evidence of a UTI TREATMENT CHOICES

38 Therapy is not indicated for asymptomatic patients REFERENCES AND FURTHER INFORMATION SIGN guidance: Management of suspected bacterial UTI in adults 5.2 GASTROINTESTINAL TRACT INFECTIONS INFECTIOUS DIARRHOEA - GASTROENTERITIS Infectious diarrhoea Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. COLI 0157 infection. Antibiotic therapy usually not indicated for bacterial infection unless patient systemically unwell. If systemically unwell and campylobacter suspected (e.g. undercooked meat and abdominal pain), consider Clarithromycin tablets mg BD for 5-7 days if treated early (within 3 days) If giardia is confirmed or suspected - tinidazole 2g single dose is the treatment of choice Fluid replacement essential REFERENCES AND FURTHER INFORMATION

39 NICE Clinical Knowledge Summaries: gastroenteritis TRAVELLERS' DIARRHOEA Traveller's diarrhoea Prophylaxis rarely, if ever, indicated. Consider standby antimicrobial only for patients at high risk of severe illness, or visiting high-risk areas. Standby: Azithromycin tablets Prophylaxis/treatment: Bismuth Subsalicylate (eg Pepto Bismol - may be purchased from a pharmacy) 500mg OD 1 to 3 days 2 tablets QDS 2 days References and further information NICE Clinical Knowledge Summaries: travellers' diarrhoea NaTHNaC: Health Professionals â travellersâ diarrhoea THREADWORMS Threadworms

40 Please note threadworms has been identified as a condition for which over the counter (OTC) medicines should not routinely be prescribed in primary care and self care may be more appropriate. Please refer to East Kent guidance. Due to licensing restrictions on the OTC product, prescriptions will still be required for children under 2 years and in pregnancy and breastfeeding. Self care advice Treat all household contacts at the same time PLUS advise hygiene measures for 2 weeks (hand hygiene, pants at night, morning shower (including perianal area) PLUS wash sleepwear, bed linen, and dust and vacuum on day one. Child <6 months add perianal wet wiping or washes 3 hourly during day. All patients over 6 months of age (off label if <2 years) Mebendazole 100mg STAT dose (but repeat in 2 weeks if infestation persists). Child <6 months of age Mebendazole is unlicensed, use hygiene measures alone for 6 weeks. References and further information NICE Clinical Knowledge Summaries: Threadworm BNF for Children: 4. Drugs for threadworms Conditions for which OTC items should not routinely be prescribed EKPG recommendation

41 5.2.5 C.DIFF INFECTION CLOSTRIDIUM DIFFICILE infection Review need for antibiotics, PPIs, and antiperistaltic agents and discontinue use where possible. Mild cases (<4 episodes of stool/day) may respond without metronidazole; 70% respond to metronidazole in 5 days; 92% respond to metronidazole in 14 days. If severe (T>38.5, or WCC>15, rising creatinine, or signs/symptoms of severe colitis): treat with oral vancomycin, review progress closely, and consider hospital referral. See additional advice on Clostridium difficile infection First episode: Metronidazole tablets Severe, type 027 or recurrent: oral Vancomycin On consultant microbiologist advice for recurrent disease as per EKPG recommendation: Fidaxomicin 400mg TDS 125mg QDS 200mg BD 10 to 14 days 10 to 14 days, then taper 10 days REFERENCES AND FURTHER INFORMATION Clostridium difficile - GOV.UK NICE Clinical Knowledge Summaries: Diarrhoea â antibiotic associated EKPG prescribing recomendation: Fidaxomicin Aug 2014

42 5.2.7 HELICOBACTER PYLORI Eradication of HELICOBACTER PYLORI See PHE quick reference guide for diagnostic advice: PHE H. PYLORI Always test for H.PYLORI before giving antibiotics. Treat all positives, if known DU, GU, or low grade MALToma. NNT in non-ulcer dyspepsia: 14. Do not offer eradication for GORD. Do not use clarithromycin, metronidazole or quinolone if used in the past year for any infection. Penicillin allergy: use PPI PLUS clarithromycin PLUS metronidazole. If previous clarithromycin, use PPI PLUS bismuth salt PLUS metronidazole PLUS tetracycline hydrochloride. Relapse and previous metronidazole and clarithromycin: use PPI PLUS amoxicillin PLUS either tetracycline OR levofloxacin (if tetracycline not tolerated). Retest for H. PYLORI: post DU/GU, or relapse after second-line therapy, using UBT or SAT, consider referral for endoscopy and culture. Please note: PPI dose is TWICE DAILY Always use PPI PPI PLUS 2 antibiotics Amoxicillin capsules PLUS Clarithromycin tablets OR Metronidazole tablets 1000mg BD 500mg BD 400mg BD Penicillin allergy and previous clarithromycin: PPI WITH Bismuth Subsalicylate and 2 antibiotics Bismuth Subsalicylate PLUS Metronidazole tablets PLUS Tetracycline tablets Relapse: PPI PLUS Amoxicillin capsules PLUS Tetracycline tablets OR 525mg QDS 400mg BD 500mg QDS 1000mg BD 500mg QDS First line 7 days Relapse 10 days; MALToma 14 days

43 Levofloxacin 250mg BD Third line on advice: PPI WITH Bismuth Subsalicylate PLUS 2 antibiotics as above not previously used OR Rifabutin 525mg QDS 150mg BD 10 days References and further information NICE CKS Dyspepsia - proven peptic ulcer NICE CG184: Dyspepsia and gastro-oesophageal reflux disease PHE H. PYLORI ORAL CANDIDIASIS Oral candidiasis Topical azoles more effective than topical nystatin. Oral candidiasis rare in immunocompetent adults; consider undiagnosed risk factors including HIV. Use 50mg Fluconazole if extensive/severe candidiasis; if HIV or immunocompromised, use 100mg Fluconazole. Treatment Miconazole oral gel 2.5ml of 24mg/ml QDS for 7 days; continue for 7 days after resolved

44 If miconazole not tolerated Nystatin suspension (Nystan brand most cost effective) 100,000 units/ml 1ml QDS (half in each side) for 7 days; continue for 2 days after resolved Fluconazole orally 50mg OD OR 100mg OD if HIV or immunosuppression for 7 to 14 days REFERENCES AND FURTHER INFORMATION NICE CKS Candida Oral 5.3 GENITAL TRACT INFECTIONS STI SCREENING STI screening People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and partners to GUM service. Risk factors: <25 years of age, no condom use, recent (<12 months)/frequent change of partner, symptomatic partner, area of high HIV CHLAMYDIA TRACHOMATIS/URETHRITIS

45 Chlamydia trachomatis/urethritis Prescribing notes and general advice Opportunistically screen all aged 15 â 24 years. Treat partners and refer to local GUM service. Test positives for reinfection at 3 months. In pregnancy or breastfeeding: azithromycin is the most effective option. Due to lower cure rate in pregnancy, test for cure at least 3 weeks after end of treatment. Sexual intercourse (including oral sex) should be avoided until both the person diagnosed with chlamydia and any partners have completed the course of treatment. (If single dose azithromycin is given, sexual abstinence for the following 7 days is advised or until any sexual partners have completed their treatment, whichever is the longer.) First Line: Azithromycin tablets 1g stat (NB tablets are more cost effective than capsules) OR Doxycycline capsules 100mg BD for 7 days Pregnant or breastfeeding Azithromycin tablets 1g (off-label use) stat OR Erythromycin e/c tablets 500mg QDS for 7 days OR 500mg BD for 14 days

46 OR Amoxicillin capsules 500mg TDS for 7 days REFERENCES AND FURTHER INFORMATION NICE Clinical Knowledge Summaries: Chlamydia British Association for Sexual Health & HIV: Chlamydia guideline SIGN: Management of genital chlamydia trachomatis infection Use of azithromycin in pregnancy Use of erythromycin in pregnancy Use of amoxicillin in pregnancy EPIDIDYMITIS Epididymitis Usually due to Gram-negative enteric bacteria in men over 35 years with low risk of STI. If under 35 years or STI risk, refer to GUM Treatment Doxycycline capsules 100mg BD for days

47 OR Ofloxacin tablets 200mg BD for 14 days OR Ciprofloxacin tablets 500mg BD for 10 days If patient is high risk of STI: Refer to GUM clinic VAGINAL CANDIDIASIS Vaginal candidiasis All topical and oral azoles give over 80% cure. In pregnancy: avoid oral azoles and use intravaginal treatment for 7 days (more effective than shorter courses). Recurrent (>4 episodes per year): 150mg oral fluconazole every 72 hours for 3 doses induction, followed by 1 dose once a week for 6 months maintenance. Clotrimazole pessary OR 500mg pessary Stat fenticonazole OR 600mg pessary Stat Clotrimazole pessary OR 100mg pessary 6 nights oral Fluconazole 150mg Stat If recurrent: Fluconazole (induction/maintenance) 150mg every 72 hours THEN 150mg once a week 3 doses 6 months References and further information

48 NICE Clinical Knowledge Summaries: vaginal candidiasis BACTERIAL VAGINOSIS Bacterial vaginosis Oral metronidazole (MTZ) is as effective as topical treatment but is cheaper. Less relapse with 7 days of oral MTZ than 2g stat at 4 weeks. Pregnant/breastfeeding: Avoid 2g stat dose. Treating partners does not reduce relapse. First Line: Oral Metronidazole tablets 400mg BD for 7 days OR Metronidazole tablets 2g stat* *2g stat dose of metronidazole should not be used in pregnant/breastfeeding women Alternative options: Metronidazole vaginal gel 0.75% 5g applicator intravaginally at night for 5 nights.

49 OR Clindamycin cream 2% 5g applicator intravaginally at night for 7 nights REFERENCES AND FURTHER INFORMATION NICE Clinical Knowledge Summaries: Bacterial vaginosis â summary GENITAL HERPES Genital herpes Prescribing notes and general advice Advise: Saline bathing, analgesia, or topical lidocaine for pain, and discuss transmission First episode: treat within five days if new lesions or systemic symptoms, and refer to GUM. Recurrent: self-care if mild, or immediate short course antiviral treatment, or suppressive therapy if more than six episodes per year First Line Oral Aciclovir tablets 400mg TDS for 5 days Aciclovir tablets 800mg TDS for 2 days if recurrent

50 OR Valaciclovir tablets 500mg BD for 5 days OR Famciclovir tablets 250mg TDS for 5 days. Famciclovir tablets 1gram BD for 1 days if recurrent References and further information NICE Clinical Knowlege Summaries: Herpes simplex-genital GONORRHOEA Gonorrhoea Antibiotic resistance is now very high. Use IM ceftriaxone plus azithromycin and refer to GUM. Test of cure is essential. Treatment Ceftriaxone injection 500mg IM Stat PLUS Azithromycin tablets 1g Stat.

51 REFERENCES AND FURTHER INFORMATION NICE CKS Management of Gonorrhoea TRICHOMONIASIS Trichomoniasis Prescribing notes and general advice Trichomoniasis is a sexually transmitted infection. Advise sexual abstinence until treatment is completed and any partners have also been treated and followed up. Oral treatment needed as extravaginal infection common Treat partners simultaneously and refer to GUM service. In pregnancy or breastfeeding, avoid 2g single dose metronidazole (MTZ). Consider clotrimazole for symptomatic relief (but NOT cure) if MTZ declined. First Line: Metronidazole tablets 400mg BD for 5-7 days OR 2g Stat. Pregnacy to treat symptoms: Clotrimazole pessary 100mg pessary at night for 6 nights.

52 REFERENCES AND FURTHER INFORMATION NICE Clinical Knowledge Summaries: Trichomoniasis PELVIC INFLAMMATORY DISEASE Pelvic inflammatory disease Prescribing notes and general advice Refer woman and sexual contacts to GUM service. Raised CRP supports diagnosis, absent pus cells in HVS smear good negative predictive value. Exclude: ectopic, appendicitis, endometriosis, UTI, irritable bowel, complicated ovarian cyst, functional pain. Moxifloxacin has greater activity against likely pathogens, but always culture for gonorrhoea and chlamydia, and test for MYCOPLASMA GENITALIUM. If gonorrhoea likely (partner has it; sex abroad; severe symptoms), use regimen with ceftriaxone, as resistance to quinolones is high. Advise pain relief with ibuprofen or paracetamol as appropriate. Advise of the need to use a barrier method of contraception (such as a condom) until both the woman and her partner(s) have completed treatment.

53 Metronidazole tablets PLUS 400mg BD 14 days Ofloxacin tablets OR 400mg BD 14 days moxifloxacin 400mg OD 14 days Gonorrhoea suspected: Ceftriaxone injection PLUS 500mg IM Metronidazole tablets PLUS 400mg BD 14 days Doxycycline capsules 100mg BD 14 days Stat References and further information NICE Clinical Knowledge Summaries: Pelvic inflammatory disease 5.4 SKIN INFECTIONS ACNE Acne Prescribing notes and general advcie Treatment depends on the type and severity of acne. Patients with severe disease (e.g. nodulocystic acne) should be referred.

54 Treat with oral antibiotics for at least 3 months if clinical improvement continue for a further 3 months. If no improvement try an alternative antibiotic before referral. Mild (open and closed comedones) or moderate (inflammatory lesions): First line: self care (wash with mild soap; do not scrub; avoid make-up) Second line: topical retinoid or benzoyl peroxide Third line: add topical antibiotics, or consider addition of oral antibiotic. Severe (docules and cysts): add oral antibiotic (for 3 months max) and refer. Please note mild acne has been identified as a condition for which over the counter (OTC) medicines should not routinely be prescribed in primary care and self care may be more appropriate. Please refer to East Kent guidance. First Line Self care Second Line Topical retinoid apply thinly OD for 6-8 weeks Benzoyl peroxide 5% cream OD-BD for 6-8 weeks Benzoyl peroxide preparations may be purchased over the counter. Due to licensing restrictions on the OTC product, prescriptions may still be required for children under 12 years, in pregnancy and breastfeeding, for damaged skin and in the elderly. Third line Topical Clindamycin cream 1% apply Thinly BD for 12 weeks

55 If treatment failure/severe: Tetracycline tablets 500mg BD for 6-12 weeks OR Doxycycline capsules 100mg OD for 6-12 weeks (Photosensitivity is reported to be a particular problem with doxycycline, so consider avoiding this in people who are exposed to a lot of sunlight.) NOTE: Avoid oral tetracyclines in pregnant or breastfeeding women and in children younger than 12 years of age, as they are deposited in the teeth and bones of the unborn or developing child. References and further information NICE Clinical knowledge summaries: Acne vulgaris Conditions for which OTC items should not routinely be prescribed EKPG recommendation BITES (HUMAN AND ANIMAL) Bites (human and animal) Human: thorough irrigation is important. Antibiotic prophylaxis is advised. Assess risk of tetanus, rabies, HIV, and hepatitis B and C. Cat: always give prophylaxis. Dog: give prophylaxis if: puncture wound; bite to hand, foot, face, joint, tendon, or ligament; immunocompromised, cirrhotic, asplenic, or presence of prosthetic valve/joint. Penicillin allergy: Review all at 24 and 48 hours, as not all pathogens are covered. Contact a microbiologist for advice in the event of severe infection or failure to respond to antibiotics

56 Prophylaxis or treatment (animal or human) Co-amoxiclav tablets mg TDS for 7 days Animal bite penicillin allergy: Adults and children over 12 years: Metronidazole tablets 400mg TDS PLUS Doxycycline capsules 100mg BD for 7 days, review at 24 and 48 hours. Children aged less than 12 years Metronidazole and Clarithromycin â see BNF for dosing Human bite penicillin allergy: Metronidazole tablets 400mg TDS PLUS Clarithromycin tablets mg BD for 7 days, review at 24 and 48 hours. If pregnant and rash after penicillin: Ceftriaxone injection 1-2g IV or IM STAT Children doses: Metronidazole: For Child 1 month 7.5â mg/kg every 12â hours usually treated for 7 days

57 For Child 2 monthsâ 11 years 7.5â mg/kg every 8â hours (max. per dose 400â mg) usually treated for 7 days For Child 12â 17 years 400â mg every 8â hours usually treated for 7 days Clarithromycin: For Neonate 7.5â mg/kg twice daily. For Child 1 monthâ 11 years (body-weight up to 8 kg) 7.5â mg/kg twice daily. For Child 1 monthâ 11 years (body-weight 8â 11 kg) 62.5â mg twice daily. For Child 1 monthâ 11 years (body-weight 12â 19 kg) 125â mg twice daily. For Child 1 monthâ 11 years (body-weight 20â 29 kg) 187.5â mg twice daily. For Child 1 monthâ 11 years (body-weight 30â 40 kg) 250â mg twice daily.

58 For Child 12â 17 years 250â mg twice daily usually for 7â 14 days, increased to 500â mg twice daily, if required in severe infections. Co-amoxiclav: Doses for 125/31mg suspension For Neonate 0.25â ml/kilogram 3 times a day. For Child 1â 11 months 0.25â ml/kilogram 3 times a day, dose doubled in severe infection. For Child 1â 5 years 0.25â ml/kilogram 3 times a day, alternatively 5â ml 3 times a day, dose doubled in severe infection Doses for 250/62mg suspension For Child 6â 11 years 0.15â ml/kilogram 3 times a day, alternatively 5â ml 3 times a day, dose doubled in severe infection DOSES FOR 400/57MG SUSPENSION For Child 2 monthsâ 1 year 0.15â ml/kilogram twice daily, doubled in severe infection.

59 For Child 2â 6 years (body-weight 13â 21 kg) 2.5â ml twice daily, doubled in severe infection. For Child 7â 12 years (body-weight 22â 40 kg) 5â ml twice daily, doubled in severe infection. For Child 12â 17 years (body-weight 41 kg and above) 10â ml twice daily; increased if necessary to 10â ml 3 times a day, increased frequency to be used in severe infection. References and further information NICE Clinical Knowledge Summaries: Bites â human and animal CELLULITIS AND ERYSIPELAS Cellulitis Class I: patient afebrile and healthy other than cellulitis, use oral flucloxacillin alone. If river or sea water exposure: seek advice.

60 Class II: febrile and ill, or comorbidity, admit for intravenous treatment, or use OPAT (if available). Class III: toxic appearence: admit. Adding clindamycin does not improve outcomes. Erysipelas: often facial and unilateral. Use flucloxacillin for non-facial erysipelas Treatment options: Flucloxacillin capsules 500mg QDS for 7 days, if slow response continue for a further 7 days. If penicillin allergic: Clarithromycin tablets 500mg BD for 7 days, if slow response continue for a further 7 days. If penicillin allergic and on statins: Doxycycline capsules 200mg stat then 100mg OD for 7 days, if slow response continue for a further 7 days. If facial (non dental): Co-amoxiclav tablets 500/125mg TDS for 7 days, if slow response continue for a further 7 days. General Guidance: If after 14 days treatment the patient has not responded then advice should be sought from the microbiologist. References and further information NHS Clinical Knowledge Summaries: Cellulitis â acute

61 5.4.4 CHICKENPOX AND SHINGLES Varicella zoster (chickenpox) and Herpes zoster (shingles) Pregnant/immunocompromised/neonate: seek urgent specialist advice. Chickenpox: consider aciclovir if: onset of rash <24 hours, and 1 of the following: >14 years of age; severe pain; dense/oral rash; taking steroids; smoker. Use paracetamol for pain relief. Shingles: treat if >50 years (PHN rare if <50 years) and within 72 hours of rash, or if 1 of the following: active ophthalmic; Ramsey Hunt; eczema; non-truncal involvement; moderate or severe pain; moderate or severe rash. Shingles treatment if not within 72 hours: consider starting antiviral drug up to 1 week after rash onset, if high risk of severe shingles or continued vesicle formation; older age; immunocompromised; or severe pain. First Line for chicken pox and shingles: Aciclovir tablets 800mg five times a day for 7 days. Child 1 month - 2 years: 200mg 4 times daily for 5 days Child 2-5 years: 400mg 4 times daily for 5 days Child 6-11 years: 800mg 4 times daily for 5 days Child years: 800mg 5 times daily for 7 days Second Line for shingles (herpes zoster) if compliance a problem (as 10 times the cost) Valaciclovir tablets 1g TDS for 7 days

62 OR Famciclovir tablets 250mg to 500 mg TDS for 7 days OR alternatively 750mg BD for 7 days (not for children) (NB. FAMCICLOVIR IS SIGNIFICANTLY MORE EXPENSIVE, ONLY USE IF VALACICLOVIR NOT APPROPRIATE) References and further information NICE Clinical Knowledge Summaries: Chickenpox NICE Clinical Knowledge Summaries: Shingles COLD SORES Most cold sores resolve after 5 days without treatment. Cold sores Topical antivirals applied prodromally reduce duration by hours and can be purchased from a pharmacy. Please note cold sores have been identified as a condition for which over the counter (OTC) medicines should not routinely be prescribed in primary care and self care may be more appropriate. Please refer to East Kent guidance. If frequent, severe, and predictable triggers: consider oral prophylaxis: aciclovir 400mg, twice daily, for 5â 7 days.

63 References and further information NICE CKS Cold Sores Conditions for which OTC items should not routinely be prescribed EKPG recommendation ECZEMA Eczema If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve healing. In eczema with visible signs of infection, use treatment as in Impetigo. References and further information NICE Clinical Knowledge Summaries: Eczema â atopic FUNGAL INFECTION OF THE FINGERNAIL OR TOENAIL Fungal infection of the fingernail or toenail (Dermatophyte infection - nail) Prescribing notes and general advice

64 Take nail clippings: start therapy only if infection is confirmed by laboratory. Oral terbinafine is more effective than oral azole. Liver reactions rare with oral antifungals (0.1 to 1%). If candida or non-dermatophyte infection confirmed use oral Itraconazole. Topical nail lacquer is not as effective To prevent recurrence: apply weekly 1% topical antifungal cream to entire toe area For children seek specialist advice. Discuss the likely benefits and adverse effects of treatment so the person can make a fully informed choice. Treatment does not always cure the infection. Cure rates range between approximately 60â 80%. Treatment that eradicates the infection sometimes does not restore the nail's appearance to normal. The drugs need to be taken for several months, or longer for resistant nails. Unpleasant adverse effects can occur. These include headache, itching, loss of the sense of taste, gastrointestinal symptoms, rash, and fatigue. Although abnormal liver function tests are not uncommon, liver failure and other serious adverse effects are rare. First Line: Terbinafine tablets 250mg OD FINGERS: TREAT FOR 6 WEEKS TOES: TREAT FOR 12 WEEKS Terbinafine is fungicidal, so treatment time is shorter than with fungistatic imidazoles. Second Line:

65 Itraconazole capsules 200mg BD FINGERS: 7 DAYS TREATMENT IN EACH MONTH (IE REPEAT AFTER 21 DAY INTERVAL) FOR 2 MONTHS TOES: 7 DAYS TREATMENT IN EACH MONTH (IE REPEAT AFTER 21 DAY INTERVAL) FOR 3 MONTHS NOTE: Stop treatment when continual, new, healthy, proximal nail growth References and further information NICE Clinical Knowledge Summaries: Fungal nail infection FUNGAL SKIN INFECTION Fungal skin infection (Dermatophyte infection - skin) Most cases: useterbinafine as fungicidal: treatment time is shorter than with fungistatic imidazoles. If candida possible, use imidazole. If intractable, or scalp: send skin scrapings for culture and if infection confirmed, use ORAL terbinafine/itraconazole. Scalp: discuss with specialist, oral therapy indicated. First Line:

66 Terbinafine cream 1% topical OD-BD for 1-4 weeks Second Line: Imidazole topical cream OD-BD for 4-6 weeks For athletes foot only: Please note athletes foot has been identified as a condition for which over the counter (OTC) medicines should not routinely be prescribed in primary care and self care may be more appropriate. Please refer to East Kent guidance. Preparations containing miconazole or terbenafine for athletes foot may be purchased OTC. Due to licensing restrictions on the OTC products, prescriptions may still be required for children under 16 years, in pregnancy and breastfeeding and for diabetic patients. Patients with lymphodema or history of lower limb cellulitis are also an exception to the guidance. Prescription only treatment: Undecanoic acid + dichlorophen (Mycota ) spray application OD-BD for 4-6 weeks References and further information NICE CKS: Fungal skin infection â body and groin NICE CKS: Fungal skin infection â foot NICE CKS: Fungal skin infection â scalp Conditions for which OTC items should not routinely be prescribed EKPG recommendation FOOT AND LEG ULCERS

67 Foot and leg ulcers Ulcers always colonised. Bacteria will always be present. Antibiotics do not improve healing unless active infection. If signs of active infection*, send pre-treatment swab. Review antibiotics after culture results. *Culture swabs and antibiotics are ONLY indicated if there is evidence of clinical infection i.e. cellulitis with >2cm surrounding erythema, increased pain, purulent exudate, odour, enlarging ulcer or pyrexia. Review after culture results. Anaerobes may be significant. Specialist guidance should be sought for diabetics. In these patients coliform/pseudomonas infections may be significant. First Line: Active infection if cellulitis/increased pain/pyrexia/purulent exudate/odour. If active infection: Flucloxacillin capsules 500mg QDS for 7 days, if slow response continue for a further 7 days. If penicillin allergic Active infection if cellulitis/increased pain/pyrexia/purulent exudate/odour. If active infection: Clarithromycin tablets 500mg BD for 7 days, if slow response continue for a further 7 days. Non-healing ulcers: Antimicrobial reactive oxygen gel may reduce bacterial load.

68 References and further information NICE Clinical Knowledge Summaries: Leg ulcer â venous IMPETIGO Impetigo Prescribing notes and general advice Reserve topical antibiotics for very localised lesions to reduce the risk of resistance. Reserve mupirocin for MRSA. For extensive, severe or bullous impetigo, use oral antibiotics. Hygiene measures are important to aid healing and stop the infection spreading to other sites on the body and to other people. Children and adults should stay away from school or work until the lesions are dry and scabbed over, or, if the lesions are still crusted or weeping, for 48 hours after antibiotic treatment has started. Topical choice:

69 Fusidic acid cream apply thinly TDS for 5 days More severe infection: Flucloxacillin capsules oral mg QDS for 7 days Flucloxacillin dosing in children: Child 1 monthâ 1 year 62.5â 125mg 4 times a day for 7 days. Child 2â 9 years 125â 250mg 4 times a day for 7 days. Child 10â 17 years 250â 500mg 4 times a day for 7 days. If penicillin allergic: Clarithromycin tablets oral mg BD for 7 days Clarithromycin dosing for children Child 1 month - 11 years: Body weight under 8kg: 7.5mg/kg twice daily for 7 days Body weight 8kg - 11kg: 62.5mg twice daily for 7 days Body weight 12kg - 19kg: 125mg twice daily for 7 days Body weight 20kg - 29kg: 187.5mg twice daily for 7 days Body weight 30kg - 40kg: 250mg twice daily for 7 days Child years: 250mg twice daily for 7 days, increased if necessary in severe infections to 500mg twice daily for up to 14 days

70 MRSA only: Mupirocin 2% ointment TDS for 5 days References and further information NICE Clinical Knowledge Summaries: Impetigo MASTITIS Mastitis Prescribing notes and general advice S. AUREUS is the most common infection pathogen. Suspect if woman has: a painful breast; fever and/or general malaise; a tender, red breast. Breastfeeding: oral antibiotics are appropriate, where indicated. Women should continue feeding, including from the affected breast. First Line Flucloxacillin capsules 500mg QDS for days Pinicillin allergy:

71 Erythromycin mg QDS for days OR Clarithromycin tablets 500mg BD for days References and further information NICE Clinical Knowledge Summaries: Mastitis and breast abscess PVL Panton-Valentine Leukocidin (PVL) Panton-Valentine Leukocidin (PVL) is a toxin produced by % of STAPH AUREUS from boils/abscesses. PVL strains are rare in healthy people, but severe. Suppression therapy should only be started after primary infection has resolved, as ineffective if lesions are still leaking. Risk factors for PVL: recurrent skin infections; invasive infections; MSM; if there is more than one case in a home or close community (school children; military personnel; nursing home residents; household contacts). References and further information PHE Guidance, data and analysis

72 6.1.2 SCABIES Scabies Prescribing notes and general advice Encourage the family not to delay treatment. Simultaneously (within 24 hours) treat all members of the household, close contacts and sexual contacts (even in the absence of symptoms). Pregnant or breastfeeding women should also be treated with an insecticide. Advise the individual to avoid close body contact with others until their partners and close contacts have been treated. Consider symptomatic treatment for itching eg cromamiton. Advise the person that itching may take several weeks to resolve.consider an oral sedating antihistamine (e.g. chlorphenamine) at night if the itch is interfering with sleep Machine wash (at 50Â C or above) clothes, towels, and bed linen, on the day of application of the first treatment For children under 2 months old, seek specialist advice from a paediatric dermatologist. (Scabies is rare in children under 2 months old.) First choice permethrin: Treat whole body from ear/chin downwards, and under nails. If using permethrin and patient is under 2 years, elderly or immunosuppressed, or if treating with malathion: also treat face and scalp. Home/sexual contacts: treat within 24 hours. First Line: Permethrin cream 5% 2 applications, 1 week apart.

73 Second line if allergy Malathion liquid 0.5% 2 applications, 1 week apart References and further information NICE Clinical Knowledge Summaries: Scabies TICK BITES (LYME DISEASE) Tick bites (Lyme disease) Prophylaxis: Not routinely recommended in Europe. In pregnancy, consider amoxicillin. If immunocompromised, consider prophylactic doxycycline. Risk increased if high prevalence area and the longer tick is attached to the skin. Only give prophylaxis within 72 hours of tick removal. Give safety net advice about erythema migrans and other possible symptoms that may occur within one month of tick removal. Prophylaxis: Doxycycline capsules 200mg Stat Treatment: Treat erythema migrans empirically; serology is often negative early in infection. For other suspected Lyme disease such as Neuroborreliosis (CN palsy, radiculopathy) seek advice.

74 Treatment: Doxycycline capsules First alternative: Amoxicillin capsules 100mg BD 1g TDS 21 days REFERENCES AND FURTHER INFORMATION NICE Clinical Knowledge Summaries: Lyme disease 6.2 EYE INFECTIONS CONJUNCTIVITIS Conjunctivitis Prescribing notes and general advice First line: bath/clean eyelids with cotton wool dipped in sterile saline or boiled (cooled) water, to remove crusting. Treat only if severe, as most cases are viral or self-limiting. Bacterial conjunctivitis: usually unilateral and also self-limiting. It is characterised by red eye with mucopurulent, not watery discharge. 65% and 74% resolve on placebo by days 5 and 7. Third line: fusidic acid as it has less gram-negative activity. Remove contact lenses, if worn, until all symptoms and signs of infection have completely resolved and any treatment has been completed for 24 hours.

75 Clean away infected secretions from eyelids and lashes with cotton wool soaked in water. Wash hands regularly, particularly after touching infected secretions, and to avoid sharing pillows and towels to avoid spreading infection. If symptoms persist for longer than 2 weeks the patient should reconsult for investigation of the cause. People should urgently seek medical attention if they develop marked eye pain or photophobia, loss of visual acuity, or marked redness of the eye. Advise parents that it is not necessary to exclude a child from school or childcare if they have infective conjunctivitis, unless there is an outbreak of infective conjunctivitis. Please note conjunctivitis has been identified as a condition for which over the counter (OTC) medicines should not routinely be prescribed in primary care and self care may be more appropriate. Please refer to East Kent guidance. Due to licensing restrictions on the OTC product, prescriptions may still be required for children under 2 years and in pregnancy and breastfeeding. First Line: Self care as above Second line: Chloramphenicol eye drops 0.5% DROPS OR Chloramphenicol eye ointment 1% 2 hourly for 2 days, then reduce frequency to 3â 4 times daily, or just at night if using eye ointment. Continue for 48 hours after resolution Chloramphenicol is available to purchase over the counter. Please refer to East Kent guidance. Due to licensing restrictions on the OTC product, prescriptions may still be required for children under 2 years and in pregnancy and breastfeeding. Third Line: Fusidic acid 1% gel 1% apply BD, continue for 48 hours after resolution.

76 NB. Fusidic acid 1% eye gel is significantly more expensive than chloramphenicol 0.5% eye drops, only use if treatment is absolutely necessary and chloramphenicol is contraindicated. 6.3 REFERENCES AND FURTHER INFORMATION NICE Clinical Knowledge Summaries: Conjunctivitis â infective RCGP fact sheet: Management of infective conjunctivitis in primary care Conditions for which OTC items should not routinely be prescribed EKPG recommendation BLEPHARITIS Blepharitis Prescribing notes and general advice First line: lid hygiene for symptom control, including: warm compressses; lid massage and scrubs; gental washing; avoiding cosmetics. Second line: topical antibiotics if hygiene mesasure are ineffective after 2 weeks. Signs of Meibomian gland dysfunction, or acne rosacea: consider oral antibiotics. First Line Self care Second Line Chloramphenicol eye ointment 1% apply BD for 6 week trial

77 Third line Oxytetracycline 500mg BD for 4 weeks initially then 250mg BD for 8 weeks maintenance. OR Doxycycline capsules 100mg OD for 4 weeks initially then 50mg od for 8 weeks maintenance. Reference and further information NICE Clinical Knowledge Summaries: Blepharitis 6.4 DENTAL INFECTIONS (EMERGENCY TREATMENT) Dental infection - emergency treatment Derived from the Scottish Dental Clinical Effectiveness Programme (SDCEP) 2013 Guidelines. This guidance is not designed to be a definitive guide to oral conditions, as GPs should not be involved in dental treatment. Patients presenting to non-dental primary care services with dental problems should be directed to their regular dentist, or if this is not possible, to the NHS 111 service (in England), who will be able to provided details of how to access emergency dental care. For emergency out-of-hours care in East Kent we are served by Dentaline. Their access number is For emergency appointments in the daytime patients should call 111 or to be directed to a dental practice able to see them Patients can find details of their local dentists and whether they are accepting new patients via NHS choices: Search/Dentist/LocationSearch/3

78 NOTE: ANTIBIOTICS DO NOT CURE TOOTHACHE. FIRST LINE TREATMENT IS WITH PARACETAMOL AND/OR IBUPROFEN; CODEINE IS NOT EFFECTIVE FOR TOOTHACHE. Mucosal ulceration and inflammation (simple gingivitis) Temporary pain and swelling relief can be attained with saline mouthwash (half a teaspoon salt in warm water) Use antiseptic mouthwash, if more severe and if pain limits oral hygiene to treat or prevent secondary infection. The primary cause for mucosal ulceration or inflammation (aphthous ulcers, oral lichen planus, herpes simplex infection, oral cancer) needs to be evaluated and treated. Simple saline mouthwash: half a teaspoon of salt dissolved in glass of warm water. Always spit out after use. Use until lesions resolve or less pain allows oral hygiene. Chlorhexidine %: rinse mouth for 1 minute twice daily with 10ml (do not use within 30mins of toothpaste). Always spit out after use. Use until lesions resolve or less pain allows oral hygiene. Hydrogen peroxide 6% (spit out after use): rinse mouth for 2 to 3 mins two or three times daily with 15ml diluted in half a glass of warm water. Always spit out after use. Use until lesions resolve or less pain allows oral hygiene. Acute necrotising ulcerative gingivitis Refer to dentist for scaling and hygiene advice. Antiseptic mouthwash if pain limits oral hygiene. Commence metronidazole if systemic signs and symptoms. Metronidazole tablets 400mg TDS for 3 days

79 Chlorhexidine or hydrogen peroxide mouthwash until oral hygiene possible. See dosing above in mucosal ulceration. Pericoronitis Refer to dentist for irrigation and debridement. If persistant swelling or systemic symptoms use metronidazole or amoxicillin. Use antiseptic mouthwash if pain and trismus limit oral hygiene. Amoxicillin capsules 500mg TDS for 3 days OR Metronidazole tablets 400mg TDS for 3 days Chlorhexidine or hydrogen peroxide mouthwash until oral hygiene possible. See dosing above in mucosal ulceration. Dental abcess Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics for abcess are not appropriate. Repeated antibiotics alone, without drainage are ineffective in preventing spread of infection. Antibiotics are only recommended if there are signs of severe infection, systemic symptoms or high risk of complications. Patients with severe odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing, impending airway obstruction, Ludwig's angina shoule be referred urgently for admission to protect airway, achieve surgical drainage and IV antibiotics. The empirical use of cephalosporins, co-amoxiclav, clarithromycin and clindamycin do not offer any advantage for most dental patients and should only be used if no response to first line drugs when referral is the preferred option.

80 IF PUS IS PRESENT: refer for drainage, tooth extraction or root canal. Send pus for microbiology. IF SPREADING INFECTION: (lymph node involvement or systemic signs i.e. fever and malaise) ADD metronidazole. TRUE PENICILLIN ALLERGY: use clarithromycin. If severe. refer to hospital. First Line: Amoxicillin capsules 500mg to 1g TDS for up to 5 days (review at 3 days), if spreading infection, ADD Metronidazole tablets 400mg TDS for 5 days OR Phenoxymethylpenicillin tablets 500mg-1g QDS for up to 5 days (review at 3 days), if spreading infection, ADD Metronidazole tablets 400mg TDS for 5 days (review at 3 days). True penicillin allergy: Clarithromycin tablets 500mg BD for up to 5 days (review at 3 days), if spreading infection ADD Metronidazole tablets 400mg TDS for 5 days (review at 3 days). References and further information Scottish Dental Clinical Effectiveness Programme (SDCEP) 2013 Guidelines NICE Clinical Knowledge Summaries: Dental abscess Management of Acute Dental Problems, Quick Reference Guide for healthcare professionals, March 2013

81 7 SUPPORTING INFORMATION STEPS FOR GOOD ANTIMICROBIAL PRESCRIBING 10 steps for good antimicrobial prescribing practice Prescribe an antibiotic only when there is likely to be a clear clinical benefit 2. Do not prescribe an antibiotic for viral sore throat, simple coughs and colds 3. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections 4. Limit prescribing over the telephone for exceptional cases 5. Use simple generic antibiotics first whenever possible (see information in this guide) 6. Avoid broad spectrum antibiotics where a narrow spectrum agent will be effective 7. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations) 8. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones and high dose metronidazole. Short term use of trimethoprim (theoretical risk in first trimester in patients with poor diet, as folate antagonist) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus 9. Document clinical indication, duration, dose and route in patient records 10. Where a â best guessâ therapy has failed or special circumstances exist, microbiological advice can be obtained from your local microbiologist 7.3 CLOSTRIDIUM DIFFICILE CLOSTRIDIUM DIFFICILE infection

82 CLOSTRIDIUM DIFFICILE (CDI) can be present in the gut without causing illness. It is estimated to be present in the lower bowel of around 5% of the population. The natural intestinal flora normally prevent overgrowth of C.DIFF, however when antimicrobial therapy is given to patients it can upset this and allow C.DIFF to multiply. The toxins produced by C.DIFF damage the lining of the GI tract and cause symptoms ranging from mild diarrhoea to severe pseudomembranous colitis and toxic megacolon. Patients should be reviewed regularly and admission arranged if there are signs of severe disease (>5-7 stools/day, temperature >38.5 o C, hypotension, tachycardia, ileus, abdominal tenderness) In mild cases, simply stopping aggravating antibiotics is all that is required and if symptoms have settled by the time the result is known then treatment is not required. First line treatment is oral Metronidazole tablets 400mg TDS for days C. DIFFICILE can be detectable in faeces for several weeks and repeat samples are unnecessary. Treat according to symptoms and do not send repeat samples unless requested by a Consultant Microbiologist. Antibiotic use should be avoided for a minimum of 6 weeks after an episode of CDI or in C. DIFFICILE carriers. If there is evidence of another infection that requires treatment during this period, then microbiological advice should be sought. Up to 20% of cases relapse after resolution of symptoms. Relapse is defined by reoccurrence of symptoms, there is no need for further samples. Recurrences should be treated promptly with metronidazole or, if the initial illness was severe, oral vancomycin. After first relapse, the risk of another is increased. Discuss all relapses with a Consultant Microbiologist for further advice: o Ensure that all documentation and onward referrals to other services includes details of CLOSTRIDIUM DIFFICILE history o If the patient lives in a shared care setting ensure that IPC advice is given o Ensure that the patient is given an advice leaflet o Probiotics have a limited use for the prevention and treatment of CLOSTRIDIUM DIFFICILE and cannot be recommended. Understanding C. DIFFICILE results Diarrhoeal stools are tested for both C. DIFFICILE antigen (which indicates the presence of the organism in the gut) and C. DIFFICILE toxin (which is produced by the organism and causes damage to the gut).

83 C. DIFFICILE GDH antigen C. DIFFICILE toxin Interpretation No evidence of C. DIFFICILE infection NOT detected DETECTED DETECTED NOT detected NOT detected DETECTED Consider other causes including viruses. Stop any C. DIFFICILE treatment that has been commenced If symptoms persist send repeat sample in 5 days This could be C. DIFFICILE colonisation or early disease Stop antibiotics if possible Correlate with the clinical picture and treat if appropriate Diarrhoea is very likely to be caused by C. DIFFICILE Stop antibiotics if possible Treatment for C. DIFFICILE should be commenced A root cause analysis will be initiated Seek Consultant Microbiologist advice on if unsure â out of hours contact via hospital switchboard. Prudent antimicrobial prescribing

84 Only prescribe antimicrobials when indicated by the clinical condition of the patient or the results of microbiological investigation. Do not prescribe antimicrobials for sore throat, coughs and colds in patients at low risk of complications. Consider a no, or delayed, antibiotic strategy where possible. If an antimicrobial is required, follow the treatment recommendations in this guide, choosing a narrow spectrum agent where possible. Broad spectrum antibiotics should be reserved for the treatment of serious infections when the pathogen is not known. Which patients are most at risk of CDI? Patients are more at risk of CDI if they are: High risk patient Frail older patients >65 years Long term conditions requiring frequent antibiotics Recent antibiotic exposure within previous 2 months Those who take Proton Pump Inhibitors (PPIs eg omeprazole, lansoprazole etc) High risk environment Contact with C.DIFF patients Recent hospital admission Lives in a shared social and/or care setting High risk antibiotics (the 4Cs)? Clindamycin Ciprofloxacin and other quinolones

85 Cephalosporins (expecially 2nd & 3rd generation) Co-amoxiclav Aminopenicillins (e.g. amoxycillin) have also been implicated in increased C. DIFFICILE infection (may be related to volume of prescribing). Compared to narrow spectrum antibiotics, broad spectrum antibiotics are more likely to significantly change gut flora. Association of acid suppressive therapies, particularly PPIs,with CDI. PPIs have been associated with an increased incidence of CDI Risk of CDI is further increased if antibiotic are used with PPIs Review on-going need for acid suppressants and consider stepdown of treatment When can broad spectrum antibiotics be recommended? There are very few indications for broad spectrum cephalosporins or quinolones in primary care. When using broad spectrum antibiotics counsel patients at risk, to be alert for signs of CDI and to stop their antibiotic and seek medical help if diarrhoea develops. If prescribing antimicrobials to patients with a history of CDI seek microbiology advice.

86 7.4 PENICILLIN ALLERGY Treating penicillin allergic patients Penicillins are among the most useful and frequently prescribed antibiotics, however as with all medicines they can cause adverse reactions. These include allergic reactions ranging from mild rash to life threatening anaphylaxis. All cases of penicillin allergy, including nature of reaction, should be recorded in the patientâ s notes. Allergy is one of the most common and important adverse effects of penicillin and related drugs such as amoxicillin (including co-amoxiclav), flucloxacillin and piperacillin and can occur in 1-10% of exposed individuals.

87 Anaphylaxis is rare, with an estimated frequency of 1-5 per 10,000 courses administered, but can be fatal. Furthermore the chemical structure of cephalosporins (cefalexin, cefuroxime etc) is similar to that of penicillins and cross-sensitivity can occur in up to 10% of patients. Penicillins are often the cornerstone of treatment for serious infections and sepsis in the hospital setting. If a patient has a documented penicillin allergy, alternative antibiotics will need to be prescribed. This could require use of quinolones or cephalosporins, with higher risk of C. DIFFICILE infection, or gentamicin or vancomycin, which are nephrotoxic and ototoxic. Optimal management of the patient may be compromised if a patient has been wrongly attributed with a penicillin allergy. All available drug sensitivity issues should be recorded. It is important to clarify and record the nature of the reaction. Check with the patient and the medical notes prior to all prescribing. Please do not label a patient as being allergic to an antibiotic on the basis of side effects of a drug (e.g. nausea, diarrhoea etc.) Type 1 reaction â Immediate anaphylaxis (IgE mediated) Any patient describing anaphylaxis following penicillin exposure must not be prescribed any penicillin again, nor any cephalosporin. Patients with a history of immediate hypersensitivity following administration of penicillin, recognisable by features of urticaria, laryngeal oedema, bronchospasm, hypotension or local swelling within 72 hours of administration, should not receive a penicillin. Patients who are truely allergic to one penicillin will be allergic to all because the hypersensitivity is related to the basic penicillin structure. Patients with a history of immediate hypersensitivity to penicillin may also react to the cephalosporins and other beta-lactam antibiotics. They should not receive these antibiotics. Type 2 reactions â Delayed reaction (non-ige mediated) More commonly penicillin hypersensitivity manifests as a rash, the typical presentation being a maculopapular, erythematous rash symmetrically disposed over the legs, buttocks and trunk.

88 Patients with a definite history of non-urticarial rash allergy to penicillin should not receive a penicillin but the likelihood of serious crosssensitivity with cephalosporins or carbapenems is very low so other non-penicillin beta lactam antibiotics can be used in these patients. Very rarely penicillins can cause pemphigus vulgaris or pemphigoid-like reactions. Penicillins and cephalosporins should not be prescribed to these patients. Patients often describe side effects such as diarrhoea or nausea as â allergiesâ, so careful history taking is extremely important to distinguish between true allergy and manageable side effects. Similarly patients reporting minor rashes restricted to small areas of the body, or who develop rashes more than 72 hours after exposure, probably do not have genuine hypersensitivity. For serious infections for which penicillins are the preferred treatment, vague histories of such reactions do not contra-indicate penicillin use. Discuss with microbiology if necessary. It is also worth noting that maculo-papular rashes can also occur in patients treated with either ampicillin or amoxicillin who have concomitant viral infections such as glandular fever. Such reactions are not allergic phenomena and do not contra-indicate future use of these or related drugs. Penicillin Allergy Risk Colour Coding For patients with a type 1 hypersensitivity reaction to penicillin: Drugs in RED are contra-indicated Drugs in ORANGE are NOT for use in patients with a severe penicillin allergy, unless at the discretion of microbiology. Use with caution in patients with a history of minor allergic symptoms. Drugs in GREEN are considered safe In life threatening infections such as bacterial meningitis, consider using 3 rd generation cephalosporins even in patients with a history of penicillin allergy.

89 7.5 EDUCATION AND TRAINING Educational resources Antimicrobial prescribing and stewardship (APS) competencies

90 The goal is to improve the quality of antimicrobial treatment and stewardship and so reduce the risks of inadequate, inappropriate and ill-effects of treatment. This will improve the safety and quality of patient care, and make a significant contribution to the reduction in the emergence and spread of antimicrobial resistance. Antimicrobial stewardship is an important element of the UK five-year antimicrobial resistance strategy. Antimicrobial resistance is a global public health issue driven by the overuse of antimicrobials and inappropriate prescribing. The increase in resistance is making antimicrobial agents less effective and contributing to infections that are hard to treat. The number of infections due to multi-drug resistant organisms is growing, however, the number of new antibiotics in the pieline is extremely limited. Antimicrobial stewardship initiatives aim to improve the prescribing of all agents, whether they target bacterial, viral, fungal, mycobacterial or protozal infections. Bacterial resistance potentially complicates the management of every infection, no matter how mild they may be at the time of first presentation. Educating the public and clinicians in the prudent use of antimicrobials as part of an antimicrobial stewardship programme is of paramount importance to preserve these crucial treatments and to help control resistance. Antimicrobial stewardship competencies were designed to complement the National Institute for Health and Care Excellence (NICE) National Prescribing Centreâ s (NPC) generic competency framework for all prescribers. Competencies are described as a â œcombination of knowledge, skills, motives and personal traitsâ, development of which should help individuals to continually improve their performance and to work more effectively. The APS competencies can be used by any independent prescriber to help develop their prescribing practice at any point in their professional development in relation to prescribing antimicrobials. PHE Antimicrobial Prescribing and Stewardship Competencies TARGET antibiotics toolkit

91 The TARGET toolkit has been developed by the RCGP, PHE and The Antimicrobial Stewardship in Primary Care (ASPIC) in collaboration with professional societies including GPs, pharmacists, microbiologists, clinicians, guidance developers and other stakeholders. The toolkit provides a wealth of information about antibiotic prescribing including: Patient information leaflets Resources for clinicians Training resources to help fulfil CPD and revalidation requirements Audit toolkits Self-assessment checklist providing strategies to help optimize antibiotic prescribing in primary care

92 7.6 ANTIBIOTIC RESISTANCE IS ONE OF THE BIGGEST THREATS FACING US TODAY. Antibiotic Guardian, an initiative developed by Public Health England (PHE) is urging members of the public and healthcare professionals to join in the campaign and take action and help make sure antibiotics work now and in the future. To become an Antibiotic Guardian people choose and enact a pledge about how they will make better use of antibiotics. What we want you to do: To slow resistance we need to cut the unnecessary use of antibiotics. We invite the public, students and educators, farmers, the veterinary and medical communities and professional organisations, to become Antibiotic Guardians. Call to action: Choose one simple pledge about how youâ ll make better use of antibiotics and help save these vital medicines from becoming obsolete. To make your pledge and become an antibiotic guardian see link below: Antibiotic Guardian - make your pledge 7.7 DELAYED PRESCRIBING Delayed prescribing and patient information leaflets

93 Delayed prescription strategies A delayed prescription strategy aims to reduce the usage of antibiotics while providing a safety net for people who genuinely need antibiotics. Usually the person should be advised to use the antibiotic prescription only if their condition has deteriorated WITHIN 3 days or not improved AFTER 3 days. The strategy can be implemented in a number of ways including: People may be issued a script and advised not to redeem it unless it is required. If necessary, the prescription can be post-dated. People can be asked to re-attend the GP surgery reception after 3 days to collect the prescription (if required). If symptoms significantly deteriorate before this time, a telephone consultation can be considered. Always give advice and reassure the patient as well as giving the prescription. Consider giving written advice (such as a patient information leaflet, see link below). TARGET RCGP - treat your infection patient leaflets 7.8 PATIENT INFORMATION Patient information leaflets There is evidence that the use of leaflets or booklets outlining the natural history of respiratory tract infections (and information about when to reconsult) can result in reduced antibiotic prescribing. Reductions in antibiotic prescribing have been shown to result in reductions in future demand for consultations. Self-care advice sheets for patients

94 These have been designed for prescribers to use with patients presenting with self-limiting respiratory tract infections for whom no prescription, or a delayed antibiotic prescription is appropriate. The advice sheets have been designed to be used as a tool for prescribers to interact with patients during the consultation, rather than as a â parting giftâ. Treat your infection - patient information leaflet TARGET RCGP - treat your infection patient leaflet